Patient Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Date of Estimate *

MM

DD

YYYY

Date of Scheduled Visit *

MM

DD

YYYY

Group Name & Address

Elite OrthoSport Physical Therapy - NPI # 1215280706 - 12121 Wilshire Blvd, Los Angeles, CA 90025

Elite OrthoSport Physical Therapy - NPI # 1215280706 - 19400 Harborgate Way, Torrance, CA 90501

Elite OrthoSport Performance - NPI# 1942953724 - 12121 Wilshire Blvd, Los Angeles, CA 90025

Physical Therapy Evaluation *

Potential CPT/Service Codes: 97161, 97162, 97163, 97164

$250 per visit

$200 per visit

Physical Therapy Visits *

Potential CPT/Service Codes: 97010, 97014, 90901, 97016, 97039, 97035, 97110, 97112, 97116, 97124, 97140, 97530, 97535, 98960, 97034

$200 per visit

$175 per visit